Unsp fx upper end of unsp tibia, subs for clos fx w nonunion

This code signifies a nonunion of a closed fracture located in the upper portion of the tibia, where the specific location of the fracture (e.g., condyle, tuberosity) is not documented. It indicates that the fracture, though previously treated, has failed to heal properly and the patient is presenting for follow-up care related to this ongoing issue.

Apply this code when a patient presents for treatment or evaluation of a previously diagnosed closed fracture of the proximal tibia that has not united, and the precise anatomical site of the fracture within the upper end of the tibia is not specified in the medical record. This is used for subsequent encounters after the initial treatment of the fracture.

• Ensure documentation clearly states "nonunion" and "closed fracture" for the upper tibia.
• Verify that this is a subsequent encounter, not the initial treatment of the fracture.
• If the specific location (e.g., medial condyle, tibial tuberosity) is documented, a more specific code should be used.